cityblock’s Transition of Care (TOC) program helps members safely navigate their post-discharge journey from acute care and hospital settings back into the community.
The TOC Registered Nurse Care Manager (RNCM) coordinates with hospital case managers to determine members’ needs and to complete discharge visits (in-home or virtual) with members and providers.
The TOC RNCM will also be available for referrals to triage members’ needs and provide clinical education, with the goal of helping ensure that members do not return to the hospital.
Assign members and initiate outreach by contacting hospital case managers to understand each member's unique needs before engaging them in the TOC program.
Complete self-efficacy and condition-specific screeners during the assess and intake phase, including behavioral health tools like PHQ-9, GAD-7, AUDIT, or DAST-10, to identify members requiring behavioral health programming.
Conduct in-person clinical exams if appropriate and collaborate with care team members to determine if a different intensity program placement is needed.
Participate in daily inpatient rounds while members are admitted, followed by post-discharge case conferences to support discharge planning.
Collaborate with the TOC Care Coordinator and TOC Behavioral Health Specialist to develop post-discharge care plans addressing needs and barriers, ensuring smooth recovery and effective hand-off to longitudinal care.
Perform regular check-ins guided by the TOC program, including post-discharge home visits and weekly follow-ups for four weeks, ensuring provider visits are completed and addressing member needs promptly.
Meet members in various community settings such as homes, SNFs, IRFs, shelters, and hospitals, providing support for both clinical and non-clinical needs.
Conduct comprehensive medication reconciliation and address contracted and company-prioritized quality gaps, ensuring proper chart documentation and appropriate ICD or CPT coding as evidence of gap closure.
Utilize care facilitation, electronic health records, and scheduling platforms to collect data, document member interactions, organize information, track tasks, and communicate effectively with the team, members, and community resources.
Track TOC-related metrics for assigned members, logging new TOC events and follow-up metrics to monitor progress effectively.
Requirements
3+ Years of experience
Graduate of an accredited school of nursing (R.N.)
Clinic Manager overseeing daily operations and patient care at Medcor's occupational health clinic. Collaborating with key stakeholders to ensure effective clinic workflows and logistics.
Clinic Manager overseeing operations in a worksite health & wellness clinic for Medcor. Responsible for patient care and collaborative health service functions in a team environment.
Manager overseeing operational aspects of laboratory services at Children’s Healthcare of Atlanta. Ensuring quality service, promoting lean work culture, and collaborating with leadership team.
Nutrition Manager overseeing dietary services and meal planning for ERC Pathlight locations. Leading a team of dietitians in a supportive healthcare environment treating eating disorders.
DAS Field Manager overseeing installation projects for Distributed Antenna Systems. Ensuring quality, safety, and project management in customer locations across Phoenix and surrounding areas.
Spa Manager responsible for managing a luxury hotel's SPA operations in Saint - Tropez. Tasks include budget management, team oversight, and client services.
Assistant Store Manager handling leasing and operations at SmartStop Self Storage in Woodlands, TX. Ensuring customer satisfaction and managing on - site projects during business hours.
RN Care Manager performing utilization management and discharge planning for acute care patients at Kent Hospital. Collaborating with healthcare teams to facilitate timely patient transitions and discharges.
RN Care Manager utilizing nursing skills for patient care coordination. Interacting with healthcare teams to ensure quality care and patient outcomes at Women & Infants Hospital.
Clinical Team Manager overseeing patient care services in home health at Elara Caring. Ensuring quality patient care and team development while collaborating with healthcare professionals.